Surgery seems, and is most likely known, to be an invention of the modern age to most. Given its common prevalence in the present day-n-age, many assume that ‘plastic’ surgery is a modern luxury even though the desire to attain physical beauty and a general curiosity regarding the human body have been a human endeavour since time immemorial. From cosmetic to reconstructive purposes, surgery has been, and is, an important part of the medical field.
In order to rectify this oversight, we’d have to ask
the question as to where did it all start? It turns out that surgery has been
around longer than most people realize and that the roots of cosmetic and
reconstructive surgery procedures go back more than a couple of millennia. The
earliest instances of surgery as we know today, date back to the 6th
Century BCE with detailed records that can be found in the Sushruta Samhita, an
important Indian medical text.
Sushruta has been widely regarded as the “Father of Surgery” owing to his
seminal and numerous contributions to the field. He was an ancient surgeon who
lived, taught and practiced his craft on the banks of the Ganges in the area
that corresponds to the present-day city of Varanasi in Northern part of India.
He was perhaps the first one to lead directive into plastic surgery, records of
which have been found well-written on papyrus leaf. This compendium called
Sushruta Samhita in its current, redacted form comprises of 184 chapters and documents
the aetiology of 1,120 illnesses, 700 medicinal plants, 64 preparations from
mineral sources and 57 preparations from animal sources. In addition to that,
over 300 surgical procedures and 120 surgical instruments have been included.
Sushruta had directed that a surgeon be equipped with 20 sharp and 101 blunt
instruments largely made of steel for specific purposes. These instruments
Owing to these developments at the time, it was in surgery that the ancient
Hindu medicine reached its zenith. Among the varied operations performed by the
surgeons, the important ones included excision of tumours, incision and
draining of abscesses, punctures to release fluid in the abdomen, extraction of
foreign bodies, repair of anal fistulas, splinting of fractures, amputations,
caesarean sections, and stitching of wounds. The most outstanding of these were
lateral lithotomy that was used frequently to remove bladder stones (vesical
calculus) as it was fairly common back then, and rhinoplasty called as the Nasikasandhana
in the texts. It is the reconstruction of the nose that really laid the
foundation for the field of surgery.
It is intriguing as to why
did a surprisingly large number of noses in India needed to be reconstructed
but the answer isn’t quite that elusive. Noses were taken to be symbols of
pride so obviously they proved to be quite tempting targets during warfare. Similarly,
the amputation of the nose was considered as a proper and just punishment for
legal transgressions and other offenses including adultery. The description of
the operation done by Sushruta is amazingly meticulous and comprehensive. The
repair was carried out by cutting a piece of tissue of the required size and
shape from the patient’s cheek or forehead and applying it to the stump of the
nose. This first written record of a forehead flap rhinoplasty is a definite
pathbreaking feat as it’s the same technique that’s still used today implying
that the derivation has been indirectly taken from the ancient source.
Skin grafts are used by modern day surgeons to restore areas that have lost protective layers of tissue due to trauma, infection, burns, as well as to repair areas where surgical intervention has resulted in loss of skin, as happens with melanoma removal. Some forms of grafts even include blood vessels and muscle like in reconstructive breast surgery. In all this the amazing aspect remains that all these techniques that are relevant today are all explained in Sushruta’s treatise.
How it came to be
Due to religious beliefs and restrictions,
Hindus were prohibited from cutting cadavers. Because of this the knowledge of
anatomy was limited. Therein came Sushruta who worked his way around these by
devising ingenious and experimental methods. His treatise recommends that a
dead body be placed in a basket and sunk in a river for seven days following
which the parts could easily be separated without the need of any cutting.
These crude methods resulted in the emphasis in Hindu anatomy being given first
to the bones and then to the muscles, ligaments, and finally the joints. The knowledge
on nerves, blood vessels, and internal organs was far from perfect. As per the
beliefs, the body was taken to be made up of three elementary substances that
represented microcosmic representatives of the three divine universal forces.
They called them spirit (air), phlegm, and bile. General health was attributed
to the normal balance of these three substances in the body since the seven
primary constituents namely blood, flesh, fat, bone, marrow, chyle, and semen
were produced by their actions.
The physicians employed all the five sense for diagnosis. Hearing was used to
distinguish the nature of the breathing, voice alteration, and the grinding
sound produced by the rubbing together of broken ends of bones. Through their
good clinical sense, their discourses contain acute references to symptoms that
had grave results. Despite their efforts, the magical and superstitious beliefs
still persisted until late in the classical period thereby affecting the
prognosis by coincidental factor as the cleanliness of the messenger sent to
fetch the physician, the nature of his conveyance, or the types of persons the
physician met on the way to the patient. Dietetic treatment was deemed
important and preceded any medicinal remedy. Fats were used both internally and
externally. The “five procedures” of the administration of emetics, purgatives,
water enemas, oil enemas, and sneezing powders were the most essential methods
of active treatment. Some other frequently administered methods were
inhalations, cupping, leeching, and bleeding.
Keeping all these in mind Sushruta, along with his selected disciples and
assistants conducted and successfully ascertained surgeries that ranged from
simple to complex ones. He dedicated at least one student to observe his
procedures in a magnified manner and take notes of each step for future
references. His popularity soon soared and patients and even medical
practitioners from overseas flocked about round the clock and it’s said that he
never turned anyone away. He made his disciples practice ‘incision’ and
‘excision’ on vegetables and leather bags filled with mud of different
densities, ‘probing’ on moth eaten or bamboo, and ‘puncturing’ on the veins of
dead animals and lotus stalks to get a feel for the human body since refrainment
was to be exercised. He was also, in a way, the pioneer of anaesthesia and
guided about the proper use of wine with incense of cannabis for the purpose.
Apart from the usage of narcotic during operations, the bleeding was stopped by
hot oils and tar.
Sushruta ascertained that a good doctor should possess medical knowledge in both its theoretical and practical forms. He wanted to expound and share all that he had learned about medicine and healing from Divodasa who was the King of Kashi (present day Varanasi). The king was believed to be the incarnation of Dhanvantari the God of Ayurvedic medicine.
Other significant and notable inclusions
Sushruta Samhita can easily be referred to as the encyclopaedia of medical learning for doctors with special importance on the Shalya tantra, a vital branch of Ayurveda the literal meaning of which is the removal of an irritating factor from the body, and Shalakya tantra that deals with prevention and treatment of diseases in and around the head.
The treatise is divided into two distinct parts that expand the scope further by describing the sciences and practices of paediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology, aphrodisiacs, and psychiatry.
The first of the two, Purva-tantra is dedicated to
Ayurveda’s four branches. It has in all about 120 chapters proportioned into
five sections that are:
1. Sutra-sthana: The introduction lays the foundation for the whole compendium
by describing the basic principles.
2. Nidana-sthana: Dedicated to aetiology which is the signs and symptoms of
important surgical diseases and those ailments which have a bearing on surgery
3. Sarira-sthana: Covers the rudiments of embryology and the anatomy of the
human body along with instructions for venesection, which is the positioning of
the patient for each vein, and protection of vital structures. The essentials
of obstetrics are also included here.
4. Kalpa-sthana: Deals mainly with the nature of poisons and their management
5. Chikitsa-sthana: Describes the principles of management of surgical
conditions including obstetrical emergencies and chapters on geriatrics and
aphrodisiacs
The second part, Uttara-tantra has been called
Aupadravika since many of the complications of surgical procedures, as well as,
fever, dysentery, cough, hiccough, krimi-roga which is the symptoms and
treatment of worms, pandu (anaemia), kamala (jaundice), etc., are described
here. It holds four specialities:
1. Shalakya: Describes various diseases of the eye, ear, nose, and head
2. Kayachikitsa: It’s about internal medicine and is the first branch of
Ayurveda where ‘kaya’ means body and ‘chikitsa’ stands for treatment
3. Kaumarabhfefefrtya: One of the most important branch amongst Ashtanga
Ayurveda as it deals with the prevention and cure of childhood diseases
4. Bhutavidya: Literally means psychiatry and the science of spirits
and deals with the diseases of mind or psychic conditions which were believed
to be even caused by ‘supernatural’ forces. Some believe that ‘bhuta’ could
even represent microscopic organisms such as virus, bacteria that aren’t
visible to the naked eye.
The remarkable aspect remains that there’s still so much to unearth in the text
that the mention of surgical techniques
of making incisions, probing, extraction of foreign bodies, alkali and thermal
cauterization, tooth extraction, excisions, and trocars for draining abscess, hydrocele
and ascitic fluid, the removal of the prostate gland, urethral stricture
dilatation, vesicolithotomy,
hernia surgery, caesarean section, management of haemorrhoids, fistulae,
laparotomy and management of intestinal obstruction, perforated intestines, and
accidental perforation of the abdomen with protrusion of omentum, are like
scratching the surface.
The inclusion of the principles of fracture management, viz., traction,
manipulation, appositions and stabilization including some measures of
rehabilitation and fitting of prosthetics is yet another astonishing component.
It enumerates six types of dislocations, twelve varieties of fractures, and
classification of the bones and their reaction to the injuries.
It also gives a classification of eye diseases including cataract surgery by
couching, or displacing the lens to improve vision.
It is no wonder then that Sushruta’s era is regarded as ‘The Golden Age of
Surgery’ in Ancient India as he took surgery to an astonishing height. The
later translations into Arabic, Latin, and English languages bear further testimony
to the worldwide popularity and acknowledgment of his great contribution to the
field as it continues to hold an important place in the medical arena.